A new approach to genetic testing for patients with prostate cancer at the University of Colorado Anschutz Cancer Center is leading to an increase in genetic testing for those who qualify, as well as an increase in genetic testing for those patients’ family members.
“This initiative started out of a desire to try to screen more patients for a clinical trial,” says cancer center member Laura Graham, MD, who recently published the results of the change in approach in the journal JCO Oncology Practice. “We had a clinical trial that was looking for patients with genetic mutations in the BRCA1 or BRCA2 genes, but in order for them to qualify, we had to know people had mutations, and we had to do that early. So we decided to implement what's called mainstream genetic testing in our multidisciplinary clinic.”
Going mainstream
Mainstream genetic testing, Graham explains, is testing that happens during a patient’s regular clinic appointment, via a blood or saliva sample, rather than asking a patient to make a separate appointment with a genetic counselor — appointments that often get lost in the shuffle of cancer treatment. CU Anschutz Cancer Center data showed that only 30% of patients with prostate cancer being seen in the multidisciplinary clinic who met criteria for genetic testing actually received it under the referral-based system.
“We thought there was significant room for improvement there, so we implemented mainstream genetic testing with the support of our genetic counselors,” Graham says. “Before patients would come into our prostate cancer multidisciplinary clinic, we would review their case and see if they met criteria for genetic testing. If they did, our nurse practitioner would play them a video that our genetic counselors had recorded about the importance of genetic testing. And then, if they agreed, they would get tested right there in clinic.”
Patients with pathogenic genetic mutations, as well as those with more complex questions, were referred to genetic counseling. This approach helped ensure that patients received timely testing while allowing genetic counselors to focus their expertise where it could have the biggest impact.
“Genetic counselors are a limited resource, and often the appointments are booked out for a long time,” Graham says. “By partnering with our genetic counselors to streamline the testing process, we were able to improve access to genetic testing while making the best use of their specialized expertise.”
Importance of genetic testing
It’s important for patients with prostate cancer who qualify to undergo genetic testing because it may allow them to enroll in clinical trials or receive more effective treatment for their cancer. Since genetic mutations can run in families, the testing can also let patients know if their family members need to be tested for the mutation. Relatives who test positive for the mutation may undergo regular cancer screening earlier than the recommended screening age or have other risk-reducing measures recommended.
“I’ve found that what really motivates people to get tested is less about them and more about their children,” Graham says. “Especially when they learn that these genes could affect their daughters, too — that their daughters could have breast cancer, ovarian cancer — that usually is pretty motivating for people to get tested.”
Impressive data
The data shows that switching to mainstream genetic testing led to 72% of eligible patients receiving genetic testing, a significant improvement from the 30% who did so before the change. Seven of 10 patients with pathogenic variants completed post-test genetic counseling, where cascade testing and preventive screening recommendations were discussed.
“Doing the mainstream testing really increased the number of men who were able to take advantage of this opportunity,” Graham says. “The other important thing about this is it represents a scalable framework that can be replicated in other cancer types like pancreatic cancer and breast cancer. I've applied for a grant that's supported by the National Comprehensive Cancer Network and Pfizer to support us rolling out mainstream testing into all the UCHealth satellite sites.”
UCHealth is a clinical partner of the CU Anschutz Cancer Center. Satellite sites include locations around the Denver metro area, including Highlands Ranch, Cherry Creek, and Lone Tree.
Widening the effort
Mainstream testing is now being introduced in oncology clinics outside of the multidisciplinary clinic for patients with metastatic prostate cancer. It’s proving to be a boon for rural patients, who tend to have lower completion rates for genetic testing.
“That makes sense, because if they're coming from far away, chances are lower that they will come back for another appointment or more testing,” Graham says. “That's something that we have identified as an area of priority within our genitourinary cancer group across the UCHealth system — central, north, and south. We're hopefully going to be working on a plan to implement this more broadly.”
Positive impact
Graham says she was glad to publish the data to show the success of the mainstream testing approach and possibly influence other cancer centers to make a similar change.
“Showing that we were able to implement this successfully was exciting,” she says. “When we did the analysis, I was a little surprised at how well we had done. There are always opportunities for improvement — we want to get that number to 100%, and of course we want to make sure everyone sees their genetic counselors — but those numbers represent hundreds of men that we've impacted.”
